Human beings have been forgetting things for as long as there have been things to remember. And they have probably been using lists to help them remember things for as long as there has been something to write with. As the consequences of lapses in memory have become more serious, the importance of these lists has increased significantly. Indeed, for over 70 years now, pilots have been using checklists to make certain that they (and the passengers and cargo) get to their destinations safely by remembering to do things that could prove fatal if forgotten. Not surprisingly, similar lists have found common use in other high risk endeavors including operating nuclear power plants and chemical manufacturing facilities.

Memory lists or “checklists” have been relatively late to come to the everyday practice of medicine, at least on the physician side of things. While checklists have been in wide use as an aide to performing routine nursing tasks (like getting patients ready for the operating room), their routine use in the operating room itself is a relatively new phenomenon. The WHO Surgical Safety Checklist was developed by an international panel of experts that included nurses, surgeons, anesthesiologists and many others.

The development took place over the several years and culminated in an international pilot study performed at eight sites around the globe. The results were published in the New England Journal of Medicine and demonstrated a marked decrease in both complications and surgically associated mortality (both fell more than 30%). The study was a pre/post experimental design and did not involve randomization of patients, surgical services or hospitals. It was however, a real world test of the checklist since even with the checklist in use, not all hospitals improved their performance on some of the safety measures as much as they could have.

Practice Gap: Human memory is limited and frail. We are prone to forget even the things that we work to memorize. The pressures of work load and emergencies increase these weaknesses even more. Surgery is a complicated process that requires the coordinated effort of a team of professionals to carry out safely. Even though we have the best of intentions, we often fail to provide the best care for every patient every time.

Closing the Practice Gap: We want to help the participants in the team training course understand the usefulness and need for a structured tool to communicate important information and assure that critical safety steps are accomplished. Having the participants actually use a checklist in a simulated setting and then debrief the experience will help those who do not use the checklist effectively become more effective and improve everyone's communication skills.


The WHO Surgical Safety Checklist has been adopted widely across the US and around the globe. Still, there are many operating rooms where it is not used. The most common objections to its use are that it “takes too long to do” and that “we already do all of the safety steps.” Practicing the use of the checklist in a simulation allows clinicians to understand that it adds little to a procedure in terms of time and that it can add much in terms of important information. The most important part of the checklist is therefore contained in the portions that encourage conversation between the nurse, surgeon and anesthesia provider. This extends to the portion that encourages introduction of personnel to one another – many feel it unnecessary because “they already know each other.” Encouraging communication between individuals who don’t normally communicate also makes people feel uncomfortable or “silly.”

Strategies to Close the Gap

Careful reading of the WHO checklist shows that it was designed to do more than be a list of reminders. Many of the 19 items on the basic checklist serve other purposes as well. The item asking for a pulse oximeter to be in place and functioning, in addition to setting a global standard for anesthesia monitoring during surgery, was also a “plea” for resources to be directed to safe surgical and anesthetic care in countries where resources are scarce. The item asking the sterility indicators be checked by the nursing staff was also placed in the hopes that the level of sterility in operating rooms might be raised since sterility indicators require sterilizers to be in use. Finally, there are two places on the WHO checklist where communication amongst surgical team members and sharing of information are both encouraged. The sharing of names, or at a minimum, asking whether all members of the operating team are “ready to proceed” not only makes sense but also gives team members a “voice” through speaking at the beginning of the procedure. If the same team is working together throughout the day, a simple check to make certain that everyone’s concerns have been taken care of is sufficient. If members change or replace one another, reintroductions are a good idea. Everyone should know how to address everyone and everyone should feel comfortable to speak when they need to.

And the sharing of a general operative plan and a short “this is what I am worried about or this is a tricky part of the operation” can prove critical if the operation becomes complicated as time passes. This last item might be termed a short “briefing” and indeed that was the intention of the panel that created the checklist. The literature regarding the impact of pre-operative briefing on the subsequent performance of the surgical team is now substantial and continuing to grow. In addition to improving communication among team members, briefings also appear to make surgical procedures more efficient [fewer trips by nurses to the “core” for things so they could stay in the room more) and led to shorter operative days.

The side benefits of the checklist are important additional reasons to use it but the most important reason is that it can improve critical communication between team members. A major reason for bringing teams into the simulated environment and for encouraging teamwork among professionals is to facilitate better communication.

As you build and present your scenarios the importance of communication as the cornerstone in the safe conduct of surgery must be demonstrated and discussed. In the scenario where the use of the checklist is practiced, consider making an important piece of information available to only some members of the team. Their success or failure to communicate that information can then be a central focus of the discussion in the scenario debriefing. In the scenario, make certain to build in the use of the checklist that is actually used in the OR at your institution. If you do not use a checklist in the OR, then use the WHO checklist as a proxy. Further, if the checklist that is used in your ORs doesn’t include a briefing or isn’t read aloud, make certain that the checklist is read aloud and that a briefing is included. If at all possible, have the participants review the use of the debriefing portion of the WHO checklist if you do not do that in your ORs as a routine.

Practicing and debriefing the checklist will help your participants carry this important tool back into the operating rooms where they work every day.

Key Points

  • The use of checklists in the operating room helps us remember to do the things that we want each patient to have done.
  • The checklist is also an important to tool that can be used to enhance communication of important information and build teamwork.
  • Don’t forget to have team members introduce themselves to each other in the simulated operation room during the process of going through a checklist. It will help to make the point that they should be doing that in every case.
  • Building a chance to “practice” the use of a checklist into your scenarios is important.

Intra-operative Briefing References

Berenholtz SM, Schumacher K, Hayanga AJ, Simon M, Goeschel C, Pronovost PJ, Shanley CJ, Welsh RJ. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2009 Aug;35(8):391-7.PMID: 19719074

Bleakley A, et al. Improving teamwork climate in operating theatres: the shift from multiprofessionalism to interprofessionalism. Journal of Interprofessional Care, 2006; 20:461–70.

Einav Y, et al. Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. Chest. 2010 Feb;137(2):443-9.

Frankel A, et al. Using the communication and teamwork skills (CATS) assessment to measure health care team performance. Joint Commission Journal on Quality and Patient Safety, 2007. 33(9): p. 549–58.

Gore DC, et al. Crew resource management improved perception of patient safety in the operating room. Am J Med Qual. 2010 Jan-Feb;25(1):60-3. Epub 2009 Dec 4.

Henrickson SE, Wadhera RK, Elbardissi AW, Wiegmann DA, Sundt TM 3rd. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009 Jun;208(6):1115-23. Epub 2009 Apr 17.PMID: 19476900

Karl R. Briefings, checklists, geese, and surgical safety. Ann Surg Oncol. 2010 Jan;17(1):8-11. No abstract available.

Khoshbin A, Lingard L, Wright JG. Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children. Can J Surg. 2009 Aug;52(4):309-315.

Lee, Steven. The Extended Surgical Time-Out: Does It Improve Quality and Prevent Wrong-Site Surgery? The Permanente Journal. 2010 Spring Volume 14 No. 1: 19-23.

Leonard M, et al The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 2004;13(Suppl 1): 85–90.

Lingard L, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008 Jan; 143 (1):12-7; discussion 18.

Lingard L, et al. Towards safer interprofessional communication: constructing a model of "utility" from preoperative team briefings. J Interprof Care. 2006 Oct;20(5):471-83.

Makary MA, et al. Operating room debriefings. Jt Comm J Qual Patient Saf. 2006 Jul;32(7):407-10, 357.

Makary MA,et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007 Feb;204(2):236-43. Epub 2006 Dec 8. 2008 Jan;143(1):12-7; discussion 18.

Makary MA, et al. Operating room briefings: working on the same page. Joint Commission Journal on Quality and Patient Safety, 2006;32:351–5.

McCafferty MH, Polk HC Jr. Patient safety and quality in surgery. Surg Clin North Am. 2007 Aug;87(4):867-81, vii. Review.

Nundy S, et al. Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg. 2008 Nov;143(11):1068-72.

Papaspyros SC, Javangula KC, Adluri RK, O'Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interact Cardiovasc Thorac Surg. 2010 Jan;10(1):43-7. Epub 2009 Oct 2.PMID: 19801374

Paull DE, et al. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Am J Surg. 2009 Nov;198(5):675-8.

Penprase B, Elstun L, Ferguson C, Schaper M, Tiller C. Preoperative communication to improve safety: a literature review. OR Nurse. 2010 Jan;4(1):31-5.

Roberts NK, Williams RG, Kim MJ, Dunnington GL. The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009 Feb;208(2):299-303. Epub 2008 Dec 4.

Wiegmann DA, Dunn WF. Changing culture: a new view of human error and patient safety. Chest. 2010 Feb;137(2):443-9.

Lingard L, et al. Towards safer interprofessional communication: constructing a model of "utility" from preoperative team briefings. J Interprof Care. 2006 Oct;20(5):471-83.

WHO Surgical Safety Checklist References

Bell R, Pontin L. How implementing the surgical safety checklist improved staff teamwork in theatre. Nurs Times. 2010 Mar 30-Apr 5;106(12):12.

Gough Ian. A surgical safety checklist for Australia and New Zealand. ANZ J Surg 80 (2010) 1–2.

Haynes AB et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14.

Kasatpibal N. Safe surgery implementation in Thailand. AORN J. 2009 Nov;90(5):743-4, 747-9. No abstract available.

Keane MJ, Marshall SD. Implementation of the World Health Organisation Surgical Safety Checklist: implications for anaesthetists. Anaesth Intensive Care. 2010 Mar;38(2):397-8.

Merry AF. Role of anesthesiologists in WHO safe surgery programs. Int Anesthesiol Clin. 2010 Spring;48(2):137-50.

Sparkes D, Rylah B. The World Health Organization Surgical Safety Checklist. Br J Hosp Med (Lond). 2010 May 6;71(5):276-280.

Truran, P. *; Critchley, R. J.; Gilliam, A. WHO saves lives? The effect of a surgical checklist on compliance to VTE prophylaxis: Patient Safety. British Journal of Surgery. 97 (Supplement 2):151, April 2010.

Vats, A. *; Nagpal, K.; Davies, R.; Darzi, A.; Vincent, C.; Moorthy, K. Evaluation of the WHO checklist on patient safety in surgery-pilot study: Patient safety 0588.[Abstract]
SourceBritish Journal of Surgery. 96 (Sup 4):21, 2009.

Vats, A, Vincent, C, Nagpal, K, Davies, R, Darzi, A, head, division, Moorthy, K. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ. 340:b5433, January 16, 2010.

Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA; Safe Surgery Saves Lives Investigators and Study Group. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010 May;251(5):976-80.

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